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Smoking-Cessation Advice from Health-Care Providers --- Canada, 2005

Tobacco use is the most preventable cause of premature death and disease in Canada. In 2002, an estimated
37,209 Canadians died from illnesses related to tobacco use, accounting for 16.6% of all deaths in Canada
(1). One of the objectives of the Canadian Federal Tobacco Control Strategy (FTCS) 2001--2011 is to reduce smoking prevalence
in Canada from 25% to 20%. Although evidence indicates that an effective and efficient way of providing
smoking-cessation information to smokers is through contact with health-care providers
(2,3), little data in Canada exist regarding
smoking-cessation advice from this group. In 2005, the Canadian Tobacco Use Monitoring Survey (CTUMS) included questions
to assess self-reported provision of cessation advice by health-care providers. This report summarizes the results of that
survey, which indicate that only half of persons who visited health-care providers in the preceding 12 months received
smoking-cessation advice, suggesting that health-care providers need to take greater advantage of opportunities to provide such
advice to smokers.

CTUMS was developed to provide Canada's federal health department (Health Canada) and its partners with
timely, reliable data on tobacco use and related topics. The 2005 CTUMS collected data from approximately
20,800 respondents during February--December 2005. The target population was residents of all provinces of Canada aged
>15 years; residents of the three territories (Yukon, Northwest Territories, and Nunavut) were excluded because of
poor telephone coverage, as were institutionalized persons. The sample design was a two-phase stratified random sample
of telephone numbers. In the first phase, households were selected using a random-digit--dialing method. In the
second phase, one or two persons (or none) from the household were selected according to household composition. Data
were
collected using computer-assisted telephone interviewing, which ensured that only valid responses were entered and
that all the correct procedures were followed. Data were weighted to provide national estimates.

CTUMS respondents who identified themselves as current
smokers* were asked about their visits to various types
of health-care providers, including physicians, dentists or dental hygienists, and pharmacists, in the 12 months before
the survey. For each health-care provider visited in the preceding 12 months, respondents were asked whether they
were advised by the provider to reduce or quit
smoking.§ Those who said they had received advice were then asked
whether they received any information on smoking-cessation aids such as nicotine patches, a product such as
Zyban®,or counseling
programs.¶

According to the 2005 CTUMS, approximately 5 million residents in Canada (weighted data), representing 19%
of the population aged >15 years, were current smokers, of whom 88% reported visiting one or more of the
specified health-care providers (physician, dentist or dental hygienist, and pharmacist) in the 12 months before the survey
(Table 1). A greater proportion of female smokers (94%) visited a health-care provider in the preceding 12 months than
male smokers (83%). Among female smokers, the highest rate of visiting a health-care provider was among respondents
aged 25--34 years (97%), and the lowest was among those aged 15--19 years (91%). In contrast, among male smokers,
the highest rate of visiting a health-care provider was among respondents aged 15--19 years (87%), and the lowest
was among those aged 25--34 years (79%). Among the current smokers who reported visiting a health-care provider in
the preceding 12 months, 54% said that they were advised to reduce or quit smoking. Rates of advice to reduce or
quit smoking were lowest among smokers aged 15--19 years (36%) and increased by age group (Table 1).

Regarding types of health-care providers, 73% of current smokers reported visiting a physician in the preceding
12 months, whereas a smaller proportion reported visiting a dentist or dental hygienist (60%) or a pharmacist
(38%) (Table 2). A greater portion of female smokers visited a physician (85%), dentist or dental hygienist (64%), or
a pharmacist (44%) compared with male smokers (65%, 57%, and 33%, respectively). The highest rate of visiting
a physician was among respondents aged >45 years (81%), visiting a dentist or dental hygienist was highest among
those aged 15--19 years (71%), and visiting a pharmacist was highest among those aged
>45 years (42%) (Table 2).

Among the current smokers who reported visiting a physician in the preceding 12 months, approximately half
(51%) said that they were advised to reduce or quit smoking. Rates of advice to reduce or quit smoking by a physician
were lowest among the youngest smokers (i.e., aged 15--19 years) (38%) and increased by age group (Table 2).
The prevalence of being advised to reduce or quit smoking by a physician among young adult (aged 20--24 years) males
and females was significantly different: 33% among males and 50% among females. Approximately 36% of respondents
were advised to reduce or quit smoking by dentists or dental hygienists, whereas 16% of respondents received this advice
from pharmacists. Overall, respondents reported a greater prevalence of pharmacists providing information on
smoking-cessation aids (84%) compared with the other two categories of health-care providers (physician, 57%, and dentist
or dental hygienist, 31%).

Editorial Note:

Although 88% of current smokers in Canada reported visiting a health-care provider in the
preceding 12 months, only half of these smokers reported
being advised to reduce or quit smoking. Health-care providers are in
a unique position to offer smoking-cessation advice and provide information on smoking-cessation aids to their
patients; however, the results of this analysis indicate that many of these opportunities are being missed.

In 2001, several Canadian health associations, including the Canadian Medical Association, Canadian
Dental Association, and Canadian Pharmacists Association, prepared a joint statement outlining the role of the
health-care provider in smoking cessation
(4). The statement focused on smoking cessation as part of a comprehensive
strategy, specifically on the role of health-care providers in helping
Canadians to stop smoking. The strategy highlighted the
need for a collaborative, multidisciplinary approach to smoking cessation, requiring members to be prepared to
discuss counseling, pharmacotherapy, ongoing support mechanisms, and relapse-prevention strategies with patients.

Although the need for smoking-cessation counseling has been recognized, barriers exist among health-care
providers, including a need for additional training regarding smoking-cessation counseling, lack of time, low priority for
tobacco-related matters, and a perceived lack of interest in quitting among patients
(5,6). Certain clinicians simply might not know how to identify smokers quickly or know which treatments are effective and how these treatments can be
provided
(7). Health-care--provider associations need to develop innovative approaches to support and motivate
health-care providers to counsel patients who smoke
(8).

The medical, dental, and pharmacist associations in Canada endorse the need to educate members regarding their
role in smoking cessation, provide members with current training and tools that will motivate and assist them in their
roles as counselors and referral agents, and increase public awareness that health-care providers can offer support and
resources to help persons stop smoking (4). Continuing education programs have been shown to substantially change the
way health-care providers counsel smokers, resulting in higher quit rates
(3). In addition, evidence-based studies
have documented that health-care--provider advice
alonecan increase smoking-cessation rates from
approximately 5% to 10%, and following up with patients who are
tryingto quit can double smoking-cessation rates
(2,3,9). Even brief interventions by health-care providers can help adult smokers to quit
(10). In addition, use of smoking-cessation
drugs has been documented to increase the cessation rate for many
patients (2).

Despite missed opportunities in smoking-cessation consultation among health-care providers, progress has been
made in decreasing smoking prevalence overall in Canada. In 2001, the Canadian government established FTCS, with the
goal of reducing the prevalence of smokers to 20% by 2011. CTUMS demonstrated a reduction in smoking
prevalence during 2001--2006 from 25% to 20% and achievement of the original 2011 goal. FTCS was
recently renewed, and new targets for 2007--2011 include further reducing smoking rates from 19% to 12%.

The findings in this report are subject to at least five limitations. First, CTUMS does not sample households
without landline telephones. Second, the survey methodology did not determine the frequency, timing, and nature of
respondent visits to health-care providers or health-care--provider advice to reduce or quit smoking or offers of information
on smoking-cessation aids. The variation in results by age might be explained, in part, by the number of visits to
health-care providers by respondents during the preceding 12 months because the frequency of visits increases with age.
In addition, the survey did not determine whether the respondents told their health-care providers that they
smoked, which would affect the prevalence of providers offering advice. For example, pharmacists might have been less likely
to ask patients whether they were smokers and might therefore have had a lower prevalence of giving cessation
advice. Likewise, the type of encounter (e.g., emergency treatment versus routine or preventive care) would affect the
likelihood that a provider would ask about smoking status and offer advice about smoking. The higher prevalence of advice to
quit or reduce smoking among females aged 20--24 years compared with males of the same age might be a result of
the nature of the visit, which was not assessed; for example, more females might have been
advised to reduce or quit as they entered their childbearing and rearing years because of 1) the health effects of smoking during pregnancy and
on children and 2) the contraindications of certain forms of birth control (i.e., pills or patches). Third, information on
visits with health-care providers is self-reported and might be influenced by
social-desirability bias or recall bias. Fourth, although CTUMS describes the association between smoking behaviors and selected variables, conclusions
regarding causation cannot be drawn from CTUMS cross-sectional data. Finally, the presented estimates of
health-care--provider provision of smoking cessation advice to reduce or quit smoking and the provision of information on cessation aids
might be an underestimate because the survey questions were only asked of current smokers. No information was
collected from persons who had recently quit smoking but who might also have visited health-care providers and
received cessation advice and information on cessation aids.

A smoker's chance of quitting increases after receiving smoking-cessation information and support from various
health-care providers in different disciplines
(2,10). Although certain health-care providers have included
smoking-cessation activities in their practices, the results indicate that either many health professionals are missing this opportunity
to provide smoking-cessation advice or that smokers are not seeking this advice from their health-care providers.
Practice guidelines to identify smokers and encourage
cessation could help increase the number of smokers who receive
smoking-cessation counseling from their health-care providers.

References

Canadian Centre on Substance Abuse. The costs of substance abuse in Canada 2002: highlights. Ottawa, Ontario: Canadian Centre on
Substance Abuse; 2006.

* Determined by response to the question: "At the present time, do you smoke every day, occasionally, or not at all?" Respondents who answered "every day"
or "occasionally" were classified as current smokers.

 "In the past 12 months, did you see a doctor?" "In the past 12 months, did you see a dentist or dental hygienist?" "In the past 12 months, did you talk with
a pharmacist?"

§ "Did the doctor advise you to reduce or quit smoking?" "Did the dentist or dental hygienist advise you to reduce or quit smoking?" "Did the pharmacist advise you
to reduce or quit smoking?"

¶ "Did the doctor provide you with information on quit-smoking aids such as the patch, a product like Zyban, or counseling programs?" "Did the dentist or
dental hygienist provide you with information on quit-smoking aids such as the patch, a product like Zyban, or counseling programs?" "Did the pharmacist provide
you with information on quit smoking aids such as the patch, a product like Zyban, or counseling programs?"

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